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Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)
NICE clinical guideline 68
Developed by the National Collaborating Centre for Chronic Conditions
NICE clinical guideline 68 Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) Ordering information You can download the following documents from www.nice.org.uk/CG068 • The NICE guideline (this document) – all the recommendations. • A quick reference guide – a summary of the recommendations for healthcare professionals. • ‘Understanding NICE guidance’ – information for patients and carers. • The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email firstname.lastname@example.org and quote: • N1621 (quick reference guide) • N1622 (‘Understanding NICE guidance’). NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer and informed by the summary of product characteristics of any drugs they are considering. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2008. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute.
Introduction ......................................................................................................4 Patient-centred care.........................................................................................7 Key priorities for implementation......................................................................8 1 Guidance ................................................................................................10 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 3 4 5 6 7 Rapid recognition of symptoms and diagnosis ................................10 Imaging in people who have had a suspected TIA or Specialist care for people with acute stroke.....................................14 Pharmacological treatments for people with acute stroke................15 Maintenance or restoration of homeostasis .....................................19 Nutrition and hydration.....................................................................20 Early mobilisation and optimum positioning of people with Avoidance of aspiration pneumonia.................................................22 Surgery for people with acute stroke ...............................................23
non-disabling stroke ...................................................................................12
Notes on the scope of the guidance .......................................................24 Implementation .......................................................................................26 Research recommendations ...................................................................26 Other versions of this guideline...............................................................29 Related NICE guidance ..........................................................................30 Updating the guideline ............................................................................31
Appendix A: The Guideline Development Group ...........................................32 Appendix B: The Guideline Review Panel .....................................................35 Appendix C: The algorithms...........................................................................36 Appendix D: Glossary of tools and criteria .....................................................37
This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). Understanding of the care processes that contribute to a better outcome has improved. NICE clinical guideline 68 – Stroke 4 . There are some differences between the recommendations made in the NICE guideline and those in the National Stroke Strategy. better recognition of people at highest risk. which is an update of the 2004 edition. with increasing numbers of patients being treated in stroke units. Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms. and interventions that are effective soon after the onset of symptoms. However. and there is now good evidence to support interventions and care processes in stroke rehabilitation. In the UK. it needs to be put into practice. The Intercollegiate Stroke Working Party (ICSWP) National Clinical Guidelines for Stroke (published July 2008). supported by regular audit. managers and service users with summaries of evidence and recommendations for clinical practice. In order for evidence from research studies to improve outcomes for patients. Over the past two decades a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of aging that inevitably results in death or severe disability.Introduction Stroke is a preventable and treatable disease. although some interventions up to 2 weeks are covered. National guidelines provide clinicians. the National Sentinel Stroke Audits have documented changes in secondary care provision over the last 10 years. Implementation of guidelines in practice. improves the processes of care and clinical outcome. This NICE guideline should also be read alongside the Department of Health National Stroke Strategy 1 . more evidence-based practice. London: Department of Health. the NICE Guideline Development Group (GDG) 1 Department of Health (2007) National Stroke Strategy. and reductions in mortality and length of hospital stay. Evidence is accumulating for more effective primary and secondary prevention strategies. includes all of the recommendations from this NICE guideline.
treatment and management of stroke.feel that their recommendations are based on evidence derived from all of the relevant literature as identified by systematic methodology. In addition. p141– 244. Most people survive a first stroke. including all aspects of care from emergency response to life after stroke.000 deaths in England and Wales in 1999. approximately 110. stroke is estimated to cost the economy around £7 billion per year. More than 900. Raftery J.000 people have a TIA. stroke was not perceived as a high priority within the NHS. In: Stevens A. First series. Each year in England.8 billion2. it should be borne in mind that some recommendations in the guideline may not be appropriate for patients who are dying or who have severe comorbidities. It accounted for over 56.000 people have a first or recurrent stroke and a further 20. who need continuing information and support. This comprises direct costs to the NHS of £2. Mant J et al.000 people in England are living with the effects of stroke. Health care needs assessment: the epidemiologically based needs assessment reviews. 2nd edition. Wade DT. 2 NICE clinical guideline 68 – Stroke 5 . (HC 452 Session 2005–2006). Winner S (2004) Health care needs assessment: stroke. Oxford: Radcliffe Medical Press. Stroke has a sudden and sometimes dramatic impact on the patient and their family. costs of informal care of £2. but often have significant morbidity. Clinicians dealing with acute care need to be mindful of the rehabilitation and secondary care needs of people with stroke to ensure a smooth transition across the different phases of care..4 billion and costs because of lost productivity and disability of £1. which represents 11% of all deaths 2 . 3 National Audit Office (2005) Reducing brain damage: faster access to better stroke care. editors. However. with half of these being dependent on other people for help with everyday activities 3 . This outlines an ambition for the diagnosis.8 billion. Incidence and prevalence Stroke is a major health problem in the UK. Until recently. a National Stroke Strategy was developed by the Department of Health in 2007. London: The Stationery Office. Health and resource burden In England. Mant J.
they do not include retinal symptoms (sudden onset of monocular visual loss). A non-disabling stroke is defined as a stroke with symptoms that last for more than 24 hours but later resolve. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. weakness or paralysis. Bulletin of the World Health Organization 54: 541–53. blurred vision. 4 Hatano S (1976) Experience from a multicentre stroke register: a preliminary report.Drugs The guideline assumes that prescribers will use a drug’s summary of product characteristics to inform their decisions for individual patients. which should be considered as part of the definition of stroke and TIA. Definitions Symptoms of stroke include numbness. For example. leaving no permanent disability. confusion and severe headache. slurred speech. Stroke is defined by the World Health Organization 4 as a clinical syndrome consisting of ‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function. The term ‘brain attack’ is sometimes used to describe any neurovascular event and may be a clearer and less ambiguous term to use. and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke. However. there are limitations to these definitions. The symptoms of a TIA usually resolve within minutes or a few hours at most. NICE clinical guideline 68 – Stroke 6 . lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin’.
People with acute stroke or TIA should have the opportunity where possible to make informed decisions about their care and treatment.uk/consent). Treatment and care. or where the stroke or TIA results in communication problems. healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from www. and the information people are given about it. A summary is available from www. Good communication between healthcare professionals and people with acute stroke or TIA.gov. which also gives details about lasting power of attorney and advance decisions about treatment. Treatment and care should take into account peoples’ needs and preferences. and to people who do not speak or read English. the person’s consent may be difficult to obtain at the time of an acute episode. is essential. families and carers should have the opportunity to be involved in decisions about treatment and care.Patient-centred care This guideline offers best practice advice on the care of adults with acute stroke or TIA.publicguardian.uk.gov. as well as their families and carers. It should be supported by evidence-based written information tailored to the person’s needs. If the person does not have the capacity to make decisions. However. Where appropriate. Healthcare professionals should also follow a code of practice accompanying the Mental Capacity Act. should be culturally appropriate. in partnership with their healthcare professionals. NICE clinical guideline 68 – Stroke 7 . It should also be accessible to people with dysphasia or additional needs such as physical. Families and carers should also be given the information and support they need.dh. sensory or learning disabilities.
2) • People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke. (1. even though they may have an ABCD2 score of 3 or below. NICE clinical guideline 68 – Stroke 8 .1) • Brain imaging should be performed immediately 7 for people with acute stroke if any of the following apply: − indications for thrombolysis or early anticoagulation treatment − on anticoagulant treatment − a known bleeding tendency − a depressed level of consciousness (Glasgow Coma Score below 13) − unexplained progressive or fluctuating symptoms 5 Specialist assessment includes exclusion of stroke mimics. whichever is sooner’. identification of vascular treatment. (1. in line with the National Stroke Strategy. including discussion of individual risk factors. It has access to equipment for monitoring and rehabilitating patients.1) • People who have had a suspected TIA who are at high risk of stroke (that is.3) Specialist care for people with acute stroke • All people with suspected stroke should be admitted directly to a specialist acute stroke unit 6 following initial assessment.1. (1. should be used outside hospital to screen for a diagnosis of stroke or TIA.1.1. (1. Regular multidisciplinary team meetings occur for goal setting.1.2.1. 7 The GDG felt that ‘immediately’ is defined as ‘ideally the next slot and definitely within 1 hour. 6 An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team.2.Key priorities for implementation Rapid recognition of symptoms and diagnosis • In people with sudden onset of neurological symptoms a validated tool. with an ABCD2 score of 4 or above) should have: − aspirin (300 mg daily) started immediately − specialist assessment 5 and investigation within 24 hours of onset of symptoms − measures for secondary prevention introduced as soon as the diagnosis is confirmed. such as FAST (Face Arm Speech Test). identification of likely causes.3. and appropriate investigation and treatment. either from the community or from the A&E department.
1.3. (1. neck stiffness or fever − severe headache at onset of stroke symptoms.1) Nutrition and hydration • On admission. (1. fluid or medication. people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food.− papilloedema.1) NICE clinical guideline 68 – Stroke 9 .6.2.
1.2 Assessment of people who have had a suspected TIA. The recommendations in this section cover the rapid diagnosis of people who have had sudden onset of symptoms that are indicative of stroke and TIA.2.1 Rapid recognition of symptoms and diagnosis There is evidence that rapid treatment improves outcome after stroke or TIA.1 Prompt recognition of symptoms of stroke and TIA In people with sudden onset of neurological symptoms a validated tool. 1.2 In people with sudden onset of neurological symptoms.1.1 Guidance The following guidance is based on the best available evidence. How to identify risk of subsequent stroke in people who have had a TIA is also covered.1. The full guideline (www.1.1.3 People who are admitted to accident and emergency (A&E) with a suspected stroke or TIA should have the diagnosis established rapidly using a validated tool.nice. and identifying those at high risk of stroke 1. should be used outside hospital to screen for a diagnosis of stroke or TIA.1. such as ROSIER (Recognition of Stroke in the Emergency Room). such as FAST (Face Arm Speech Test).1.org.1 1.1.uk/CG068fullguideline) gives details of the methods and the evidence used to develop the guidance.1. hypoglycaemia should be excluded as the cause of these symptoms. 1. 1.1 People who have had a suspected TIA (that is. they have no neurological symptoms at the time of assessment [within 24 hours]) should be assessed as soon as possible for their risk of NICE clinical guideline 68 – Stroke 10 . 1.1.
8 NICE clinical guideline 68 – Stroke 11 .2 People who have had a suspected TIA who are at high risk of stroke (that is. an ABCD2 score of 3 or below) should have: • aspirin (300 mg daily) started immediately • specialist assessment9 and investigation as soon as possible. such as ABCD2.1.2. including discussion of individual risk factors. 1.2. even though they may have an ABCD2 score of 3 or below.5 People who have had a TIA but who present late (more than 1 week after their last symptom has resolved) should be treated as though they are at lower risk of stroke.1. They also may not be relevant to patients who present late. and appropriate investigation and treatment.3 People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke. 1. who also need urgent evaluation. but definitely within 1 week of onset of symptoms • measures for secondary prevention introduced as soon as the diagnosis is confirmed.subsequent stroke using a validated scoring system 8 . including discussion of individual risk factors. These scoring systems exclude certain populations that may be at particularly high risk of stroke. identification of vascular treatment. 1.1. with an ABCD2 score of 4 or above) should have: • aspirin (300 mg daily) started immediately • specialist assessment 9 and investigation within 24 hours of onset of symptoms • measures for secondary prevention introduced as soon as the diagnosis is confirmed. such as those with recurrent TIAs and those on anticoagulation treatment. identification of likely causes.4 People who have had a suspected TIA who are at lower risk of stroke (that is.1. 9 Specialist assessment includes exclusion of stroke mimics.2.2. 1.
2. 10 Examples where brain imaging is helpful in the management of TIA are: • people being considered for carotid endarterectomy where it is uncertain whether the stroke is in the anterior or posterior circulation • people with TIA where haemorrhage needs to be excluded.1. 1. carotid endarterectomy. However. an ABCD2 score of 4 or above. and the selection of appropriate patients for.2.2.1 Suspected TIA – referral for urgent brain imaging People who have had a suspected TIA (that is. Some people who have had a stroke or TIA have narrowing of the carotid artery that may require surgical intervention. for example long duration of symptoms or people on anticoagulants • where an alternative diagnosis (for example migraine. 1.2 People who have had a suspected TIA who are at high risk of stroke (for example. or with crescendo TIA) in whom the vascular territory or pathology is uncertain 10 should undergo urgent brain imaging 11 (preferably diffusion-weighted MRI [magnetic resonance imaging]).1 1. and timing of.3 and 1. whose symptoms and signs have completely resolved within 24 hours) should be assessed by a specialist (within 1 week of symptom onset) before a decision on brain imaging is made.1.1. Sections 1.2. For more information.2. no evidence for early carotid stenting was found on which the GDG felt they could base a recommendation.4 cover the optimum timing of carotid imaging.2 Imaging in people who have had a suspected TIA or non-disabling stroke While all people with symptoms of acute stroke need urgent brain scanning. Carotid imaging is required to define the extent of carotid artery narrowing. there is less evidence to recommend brain scanning in those people whose symptoms have completely resolved by the time of assessment. This section contains recommendations about which people with suspected TIA need brain imaging and the type of imaging that is most helpful. The use of carotid stenting was also reviewed by the GDG. epilepsy or tumour) is being considered. see chapter 6 of the full guideline. NICE clinical guideline 68 – Stroke 12 .
1.3 People who have had a suspected TIA who are at lower risk of stroke (for example.4 1.2. should: The GDG felt that urgent brain imaging is defined as imaging that takes place ‘within 24 hours of onset of symptoms’.2. 1. 12 The GDG felt that brain imaging in people with a lower risk of stroke should take place ‘within 1 week of onset of symptoms’. People who present more than 1 week after their last symptom of TIA has resolved should be managed using the lowerrisk pathway.188.8.131.52 All people with suspected non-disabling stroke or TIA who after specialist assessment are considered as candidates for carotid endarterectomy should have carotid imaging within 1 week of onset of symptoms.3. in which case CT (computed tomography) scanning should be used.2.2. This is in line with the National Stroke Strategy.4. 11 NICE clinical guideline 68 – Stroke 13 . 1. severe claustrophobia. or 70–99% according to the ECST (European Carotid Surgery Trialists’ Collaborative Group) criteria. This is in line with the National Stroke Strategy.1 Type of brain imaging for people with suspected TIA People who have had a suspected TIA who need brain imaging (that is. metal fragments in eyes.2.2 1.2. some brain aneurysm clips and heart valves. 13 Contraindications to MRI include people who have any of the following: a pacemaker. shrapnel.2. an ABCD2 score of less than 4) in whom the vascular territory or pathology is uncertain10 should undergo brain imaging 12 (preferably diffusion-weighted MRI).1 Urgent carotid endarterectomy and carotid stenting People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50–99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria.3 Early carotid imaging in people with acute non-disabling stroke or TIA 1. those in whom vascular territory or pathology is uncertain) should undergo diffusion-weighted MRI except where contraindicated 13 .
or less than 70% according to the ECST criteria. lifestyle advice). either from the community or from the A&E department.3 Carotid imaging reports should clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis. 1.4. cholesterol lowering through diet and drugs. antiplatelet agents. Regular multidisciplinary team meetings occur for goal setting. It has access to equipment for monitoring and rehabilitating patients.2. 1.3.3. An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team.1.3 Specialist care for people with acute stroke This section provides recommendations about the optimum care for people with acute stroke: where they should be cared for and how soon they should undergo brain imaging. lifestyle advice). 1.2 People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria. cholesterol lowering through diet and drugs.1 1. 1. should: • not undergo surgery • receive best medical treatment (control of blood pressure.4.1 Specialist stroke units All people with suspected stroke should be admitted directly to a specialist acute stroke unit 14 following initial assessment. antiplatelet agents.2. 14 NICE clinical guideline 68 – Stroke 14 .• be assessed and referred for carotid endarterectomy within 1 week of onset of stroke or TIA symptoms • undergo surgery within a maximum of 2 weeks of onset of stroke or TIA symptoms • receive best medical treatment (control of blood pressure.
1 1. 16 The GDG felt that ‘as soon as possible’ is defined as ’within a maximum of 24 hours after onset of symptoms’.3.4 Pharmacological treatments for people with acute stroke Urgent treatment has been shown to improve outcome in stroke.2. 1.2. 1.1 1. 15 NICE clinical guideline 68 – Stroke 15 . This section contains recommendations about urgent pharmacological treatment in people with acute stroke.1 Thrombolysis with alteplase Alteplase is recommended for the treatment of acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke. It should only be administered in The GDG felt that ‘immediately’ is defined as ‘ideally the next slot and definitely within 1 hour.1.3.2 For all people with acute stroke without indications for immediate brain imaging. neck stiffness or fever • severe headache at onset of stroke symptoms. scanning should be performed as soon as possible 16 .3.2 Brain imaging for the early assessment of people with acute stroke Brain imaging should be performed immediately 15 for people with acute stroke if any of the following apply: • indications for thrombolysis or early anticoagulation treatment • on anticoagulant treatment • a known bleeding tendency • a depressed level of consciousness (Glasgow Coma Score below 13) • unexplained progressive or fluctuating symptoms • papilloedema. in line with the National Stroke Strategy.4. whichever is sooner’.1. 1.4.
and staff trained to interpret the images.asp?shown av=1 19 In accordance with its marketing authorisation.uk/data_dictionary/attributes/c/cou/critical_care_level_de.2 Alteplase should be administered only within a well organised stroke service with: • staff trained in delivering thrombolysis and in monitoring for any complications associated with thrombolysis • level 1 and level 2 nursing care staff trained in acute stroke and thrombolysis 18 • immediate access to imaging and re-imaging. ‘Critical care level’ [online].4.4. Available from: www.4.4.3 Staff in A&E departments. 18 See NHS Data Dictionary.datadictionary. including post-thrombolysis complications. can administer alteplase 19 for the treatment of acute ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support. 1. 17 NICE clinical guideline 68 – Stroke 16 . People with acute ischaemic stroke This recommendation is from ‘Alteplase for the treatment of acute ischaemic stroke’ (NICE technology appraisal guidance 122).4 Protocols should be in place for the delivery and management of thrombolysis. if appropriately trained and supported. 1. 1. 1.2 1.1.nhs.1.centres with facilities that enable it to be used in full accordance with its marketing authorisation 17 . be given: • aspirin 300 mg orally if they are not dysphagic or • aspirin 300 mg rectally or by enteral tube if they are dysphagic.4. as soon as possible but certainly within 24 hours.1.1 Aspirin and anticoagulant treatment All people presenting with acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should.2.
nice/org. Further details will be included in the forthcoming NICE clinical guideline ‘The prevention of venous thromboembolism in all hospital patients’ (publication expected in September 2009).2 Any person with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported should be given a proton pump inhibitor in addition to aspirin.Thereafter.4. or who is a current or recent smoker.2. People being discharged before 2 weeks can be started on long-term treatment earlier.6 People with stroke secondary to acute arterial dissection should be treated with either anticoagulants or antiplatelet agents. a previous history of venous thromboembolism.uk/TA090) as either of the following: • proven hypersensitivity to aspirin-containing medicines • history of severe dyspepsia induced by low-dose aspirin. 1.2.2. 1. preferably Aspirin intolerance is defined in NICE technology appraisal guidance 90 (‘Clopidogrel and modified-release dipyridamole in the prevention of occlusive vascular events’. see www. at which time definitive long-term antithrombotic treatment should be initiated. Such people should be kept under regular review if they are given prophylactic anticoagulation.2. 1. aspirin 300 mg should be continued until 2 weeks after the onset of stroke symptoms.4.4.4 Anticoagulation treatment should not be used routinely 21 for the treatment of acute stroke.5 People diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) should be given fulldose anticoagulation treatment (initially full-dose heparin and then warfarin [INR 2–3]) unless there are comorbidities that preclude its use. 20 NICE clinical guideline 68 – Stroke 17 . dehydration or comorbidities (such as malignant disease).4.4. 21 There may be a subgroup of people for whom the risk of venous thromboembolism outweighs the risk of haemorrhagic transformation.3 Any person with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin 20 should be given an alternative antiplatelet agent.2. People with stroke associated with arterial dissection 1. People considered to be at particularly high risk of venous thromboembolism include anyone with complete paralysis of the leg. People with acute venous stroke 1.
2 In people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation.4.3. anticoagulation treatment should be stopped for 1 week and aspirin 300 mg substituted.4. 1.8 Clotting levels in people with a primary intracerebral haemorrhage who were receiving anticoagulation treatment before their stroke (and have elevated INR) should be returned to normal as soon as possible. 1.3.2. 22 There was insufficient evidence to support any recommendation on the safety and efficacy of anticoagulants versus antiplatelets for the treatment of people with acute ischaemic stroke associated with antiphospholipid syndrome.3 1.7 People with antiphospholipid syndrome who have an acute ischaemic stroke should be managed in same way as people with acute ischaemic stroke without antiphospholipid syndrome 22 . by reversing the effects of the anticoagulation treatment using a combination of prothrombin complex concentrate and intravenous vitamin K.4. Reversal of anticoagulation treatment in people with haemorrhagic stroke 1. NICE clinical guideline 68 – Stroke 18 .4.1 Anticoagulation treatment for other comorbidities People with disabling ischaemic stroke who are in atrial fibrillation should be treated with aspirin 300 mg for the first 2 weeks before considering anticoagulation treatment. 1.3 People with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism should receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation.4.4. People with acute ischaemic stroke associated with antiphospholipid syndrome 1.2.3.as part of a randomised controlled trial to compare the effects of the two treatments.
184.108.40.206.4 People with haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary embolism should have treatment to prevent the development of further pulmonary emboli using either anticoagulation or a caval filter.1 Statin treatment Immediate initiation of statin treatment is not recommended in people with acute stroke 23 . 1.4. 1.4. 220.127.116.11 18.104.22.168. This section contains recommendations on oxygen supplementation.1 Supplemental oxygen therapy People who have had a stroke should receive supplemental oxygen only if their oxygen saturation drops below 95%.5 Maintenance or restoration of homeostasis A key element of care for people with acute stroke is the maintenance of cerebral blood flow and oxygenation to prevent further brain damage after stroke.4 1. 1. which can be achieved by the use of intravenous insulin and glucose.3. and acute blood pressure manipulation. 1. NICE clinical guideline 68 – Stroke 19 .1 1. should be provided to all adults with diabetes who have threatened or actual myocardial infarction 23 The consensus of the GDG is that it would be safe to start statins after 48 hours.1.2 People with acute stroke who are already receiving statins should continue their statin treatment.2.1 Blood sugar control People with acute stroke should be treated to maintain a blood glucose concentration between 4 and 11 mmol/litre.5.4.2 Optimal insulin therapy. The routine use of supplemental oxygen is not recommended in people with acute stroke who are not hypoxic.4. maintenance of normoglycaemia.
1.or stroke.2 If the admission screen indicates problems with swallowing.6 Nutrition and hydration Many people with acute stroke are unable to swallow safely. 1. hydration and nutrition.6. preferably within 24 hours of admission and not more than 72 hours afterwards.6. 1. Critical care and emergency departments should have a protocol for such management 24 .5.1.1 Blood pressure control Anti-hypertensive treatment in people with acute stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues: • hypertensive encephalopathy • hypertensive nephropathy • hypertensive cardiac failure/myocardial infarction • aortic dissection • pre-eclampsia/eclampsia • intracerebral haemorrhage with systolic blood pressure over 200 mmHg. people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food. fluid or medication. This recommendation is from ‘Type 1 diabetes: diagnosis and management of type 1 diabetes in children.5. 1. 24 NICE clinical guideline 68 – Stroke 20 .1.5. This section provides recommendations on assessment of swallowing.6. and may require supplemental hydration and nutrition.3.3.2 Blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for thrombolysis. 1.1 Assessment of swallowing function On admission. the person should have a specialist assessment of swallowing. young people and adults’ (NICE clinical guideline 15).3 1.1 1.
1. 1. 1. may be used to do this 26 .6.6.6. 1.4 People with acute stroke who are unable to take adequate nutrition and fluids orally should: • receive tube feeding with a nasogastric tube within 24 hours of admission • be considered for a nasal bridle tube or gastrostomy if they are unable to tolerate a nasogastric tube • be referred to an appropriately trained healthcare professional for detailed nutritional assessment. enteral tube feeding and parenteral nutrition’ (NICE clinical guideline 32).2. 25 This recommendation is adapted from ‘Nutrition support in adults: oral nutrition support.1 Oral nutritional supplementation All hospital inpatients on admission should be screened for malnutrition and the risk of malnutrition. individualised advice and monitoring.2 Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake.6. should be: • re-assessed and considered for instrumental examination • referred for dietary advice. poor oral health and reduced ability to self-feed will affect nutrition in people with stroke. Screening should be repeated weekly for inpatients 25 . 1.3 When screening for malnutrition and the risk of malnutrition.1.1. healthcare professionals should be aware that dysphagia.2. 26 This recommendation is from NICE clinical guideline 32. NICE clinical guideline 68 – Stroke 21 .6.6. The Malnutrition Universal Screening Tool (MUST). or who require tube feeding or dietary modification for 3 days.2 1.3 People with suspected aspiration on specialist assessment. for example.2.
4 Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training26.7.2. 1. NICE clinical guideline 68 – Stroke 22 .6. This may include oral nutritional supplements.7.6. Sitting up will help to maintain oxygen saturation and reduce the likelihood of hypostatic pneumonia. food and fluids should be given in a form that can be swallowed without aspiration.1. 1.2. 1.1 People with acute stroke should be mobilised as soon as possible (when their clinical condition permits) as part of an active management programme in a specialist stroke unit. specialist dietary advice and/or tube feeding.6 Nutrition support should be initiated for people with stroke who are at risk of malnutrition. 1. 1. 1.2 People with acute stroke should be helped to sit up as soon as possible (when their clinical condition permits).5 Routine nutritional supplementation is not recommended for people with acute stroke who are adequately nourished on admission.8 Avoidance of aspiration pneumonia Aspiration pneumonia is a complication of stroke that is associated with increased mortality and poor outcomes.2. 1.7 All people with acute stroke should have their hydration assessed on admission.22.214.171.124. following specialist assessment of swallowing.1 In people with dysphagia. reviewed regularly and managed so that normal hydration is maintained.7 Early mobilisation and optimum positioning of people with acute stroke Early mobilisation is considered a key element of acute stroke care.1.1. 1.8.
1. 126.96.36.199.1 Surgical referral for decompressive hemicraniectomy People with middle cerebral artery infarction who meet all of the criteria below should be considered for decompressive NICE clinical guideline 68 – Stroke 23 .9 Surgery for people with acute stroke There is evidence that neurosurgical treatment may be indicated for a very small number of carefully selected people with stroke.9.9.9. 1. 1.9.1 Surgical referral for acute intracerebral haemorrhage Stroke services should agree protocols for the monitoring.2 188.8.131.52 People with intracranial haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary.3 Previously fit people should be considered for surgical intervention following primary intracranial haemorrhage if they have hydrocephalus.4 People with any of the following rarely require surgical intervention and should receive medical treatment initially: • small deep haemorrhages • lobar haemorrhage without either hydrocephalus or rapid neurological deterioration • a large haemorrhage and significant comorbidities before the stroke • a score on the Glasgow Coma Scale of below 8 unless this is because of hydrocephalus • posterior fossa haemorrhage. referral and transfer of people to regional neurosurgical centres for the management of symptomatic hydrocephalus.1 1.9. 1.9. This section contains recommendations for surgical intervention in people with intracerebral haemorrhage or severe middle cerebral artery infarction.1.9.
They should be referred within 24 hours of onset of symptoms and treated within a maximum of 48 hours. • Aged 60 years or under. NICE clinical guideline 68 – Stroke 24 . This includes: − first and recurrent events − thrombotic and embolic events − primary intracerebral haemorrhage of any cause. • Signs on CT of an infarct of at least 50% of the middle cerebral artery territory. with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side.nice.uk/guidance/index. The scope of this guideline is available from www. or infarct volume greater than 145 cm3 as shown on diffusionweighted MRI. with a score on the National Institutes of Health Stroke Scale (NIHSS) of above 15. cerebral infarction or cerebral haemorrhage.jsp?action=download&o=34392 Groups that are covered • People with transient ischaemic attacks (TIAs) or completed strokes. 1.2. • Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS. an acute neurological event presumed to be vascular in origin and causing cerebral ischaemia.hemicraniectomy. including venous thrombosis. • Clinical deficits suggestive of infarction in the territory of the middle cerebral artery.org.2 People who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals skilled in neurological assessment.9. that is. 2 Notes on the scope of the guidance NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.
org. published April 2007). which is available from www.nice. NICE clinical guideline 68 – Stroke 25 . the public and the NHS’ (third edition. The Centre established a Guideline Development Group (see appendix A). An independent Guideline Review Panel oversaw the development of the guideline (see appendix B). There is more information in the booklet: ‘The guideline development process: an overview for stakeholders.uk and quote reference N1233).Areas and groups that are not covered • Specific issues relating to the general management of underlying conditions are not considered.org. How this guideline was developed NICE commissioned the National Collaborating Centre for Chronic Conditions to develop this guideline. • People with subarachnoid haemorrhage. • Children (aged 16 years and under).uk/guidelinesprocess or from NICE publications (phone 0845 003 7783 or email publications@nice. which reviewed the evidence and developed the recommendations. but immediate management to reduce the extent of brain damage is included.
uk). • Slides highlighting key messages for local discussion. • Costing tools: − costing report to estimate the national savings and costs associated with implementation − costing template to estimate the local costs and savings involved. However.gov. based on its review of evidence. NICE has developed tools to help organisations implement this guidance (listed below). Current clinical practice dictates that those people with clinical evidence of aspiration are given ‘nil by mouth’ or are given modified (thickened) oral fluids.1 Avoidance of aspiration pneumonia Does the withdrawal of oral liquids or the use of modified (thickened) oral fluids prevent the development of aspiration pneumonia after an acute stroke? Why this is important People with dysphagia after an acute stroke are at higher risk of aspiration pneumonia.3 Implementation The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’ (available from www. The GDG considered how best to reduce the likelihood of people with acute stroke developing aspiration pneumonia. there is little NICE clinical guideline 68 – Stroke 26 .dh.uk/CG068). but there was insufficient evidence on which to base a recommendation. 4 Research recommendations The Guideline Development Group has made the following recommendations for research.org. 4. to improve NICE guidance and patient care in the future. These are available on our website (www. • Audit support for monitoring local practice. Implementation of clinical guidelines forms part of the developmental standard D2.nice. Core standard C5 says that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.
evidence to suggest that withdrawal or modification of fluids reduces the incidence of pneumonia. The research question to be addressed is whether modified-release dipyridamole or clopidogrel with aspirin improves outcome compared with aspirin alone when administered early after acute ischaemic stroke.3 Aspirin treatment in acute ischaemic stroke Should a person who has a stroke or a TIA and is already taking aspirin be prescribed the same or an increased dose of aspirin after the stroke? Why this is important Many people take aspirin routinely for the secondary or primary prevention of vascular disease. the combination of modified-release dipyridamole with aspirin improves outcome compared with aspirin alone. It is not known whether antiplatelet agents other than aspirin (alone or in combination) may be more effective than aspirin alone in the acute phase of ischaemic stroke. 4. The research question is whether allowing people with evidence of aspiration free access to water predisposes them to the development of aspiration pneumonia compared with withdrawal of oral liquids or the use of modified (thickened) oral fluids. Medications are not given orally. and patients may be distressed by the withholding of oral fluids. and aspirated saliva (up to 2 litres/day) may be infected as a result. Clopidogrel. administered with aspirin. 4. improves outcome after myocardial infarction. When a person who is taking 75 mg aspirin daily has a NICE clinical guideline 68 – Stroke 27 .2 Aspirin and anticoagulant treatment for acute ischaemic stroke Does modified-release dipyridamole or clopidogrel with aspirin improve outcome compared with aspirin alone when administered early after acute ischaemic stroke? Why this is important Aspirin administered within 48 hours of acute ischaemic stroke improves outcome compared with no treatment or early anticoagulation. In the secondary prevention of stroke. Oral hygiene is impaired by the withdrawal of oral fluids.
The effect of raised blood pressure may differ between people with NICE clinical guideline 68 – Stroke 28 . The research question to be addressed is whether a person already on aspirin who has a stroke or TIA should be offered the same or an increased dose of aspirin. After stroke.4 Early mobilisation and optimum positioning of people with acute stroke How safe and effective is very early mobilisation delivered by appropriately trained healthcare professionals after stroke? Why this is important Most people with stroke are nursed in bed for at least the first day after their admission to the stroke unit. There are concerns about the effect of very early mobilisation on blood pressure and cerebral perfusion pressure. The severity of limb weakness or incoordination and reduced awareness or an impaired level of consciousness may make mobilisation potentially hazardous. However. even apparently small changes in blood pressure may be associated with alterations in cerebral perfusion pressure. There could be benefits for motor and sensory recovery. 4. A sudden drop in blood pressure to an apparently ‘normal’ level may have very marked effects on the damaged brain in a person who had elevated blood pressure before the stroke.5 stroke? Blood pressure control How safe and effective is the early manipulation of blood pressure after Why this is important Many people with stroke have pre-existing hypertension. and patient motivation. there is no evidence to guide clinicians on whether to maintain or increase the dose. 4. for which they may be receiving treatment. early mobilisation may have beneficial effects on oxygenation and lead to a reduction in complications such as venous thromboembolism and hypostatic pneumonia. The research question to be addressed is whether very early mobilisation with the aid of appropriately trained professionals is safe and improves outcome compared with standard care.stroke or TIA. which may affect the ability of damaged neurones to survive.
as well as comparing their relative safety and cost effectiveness.rcplondon. NICE clinical guideline 68 – Stroke 29 . It is not known whether a reduction in blood pressure after stroke is beneficial or harmful. and whether elevation of blood pressure under certain circumstances might be associated with better outcome. It is published by the National Collaborating Centre for Chronic Conditions. and is available from www. The research question to be addressed is whether early manipulation of blood pressure after stroke is safe and improves outcome compared with standard care. our website (www. 'Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)'.nlh.6 Safety and efficacy of carotid stenting What is the safety and efficacy of carotid stenting compared with carotid endarterectomy when these procedures are carried out within 2 weeks of TIA or recovered stroke? Why this is important Carotid stenting is less invasive than carotid endarterectomy and might be safer.uk/CG068fullguideline) and the National Library for Health (www.ac.ischaemic stroke and those with haemorrhagic stroke.nhs. 5 5. A randomised controlled trial comparing these interventions early after stroke would determine which of them is associated with the best outcome. 4.nice. neither the risk of stroke nor long-term outcomes after early carotid stenting are known. contains details of the methods and evidence used to develop the guideline. particularly for patients very soon after a TIA or stroke. However.org.1 Other versions of this guideline Full guideline The full guideline.uk).uk/pubs/brochure.aspx?e=250. for whom the risks of general anaesthetic might be high.
NICE clinical guideline 32 (2006).uk/CG067 Alteplase for the treatment of acute ischaemic stroke. Available from: www.uk/CG032 NICE clinical guideline 68 – Stroke 30 .org.2 Quick reference guide A quick reference guide for healthcare professionals is available from www. We encourage NHS and voluntary sector organisations to use text from this booklet in their own information about stroke and TIA.nice. enteral tube feeding and parenteral nutrition.org. NICE technology appraisal 122 (2007). phone NICE publications on 0845 003 7783 or email email@example.com/TA122 Hypertension: management of hypertension in adults in primary care. 5.nice.org.org. Available from: www.uk/CG068quickrefguide For printed copies. NICE clinical guideline 67 (2008).uk (quote reference number N1621).nice.nice.org.org. Available from: www.uk (quote reference number N1622). NICE clinical guideline 34 (2006).org.uk/CG034 Nutrition support in adults: oral nutrition support. phone NICE publications on 0845 003 7783 or email publications@nice. 6 Related NICE guidance Published Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease.nice.5.nice.3 ‘Understanding NICE guidance’ Information for patients and carers (‘Understanding NICE guidance’) is available from www.uk/CG068publicinfo For printed copies. Available from: www.org.
we may decide to do a more rapid update of some recommendations.nice. Available from: www.org.uk): • The prevention of venous thromboembolism in all hospital patients.nice.uk/CG015 Under development NICE is developing the following guidance (details available from www.org. We check for new evidence 2 and 4 years after publication. If important new evidence is published at other times. NICE clinical guideline 68 – Stroke 31 . to decide whether all or part of the guideline should be updated. 7 Updating the guideline NICE clinical guidelines are updated as needed so that recommendations take into account important new information.org.uk/TA090 Type 1 diabetes: diagnosis and management of type 1 diabetes in children.nice. NICE clinical guideline 15 (2004). NICE clinical guideline (publication expected September 2009).Clopidogrel and modified-release dipyridamole in the prevention of occlusive vascular events. Available from: www. NICE technology appraisal 90 (2005). young people and adults.
University of East Anglia. Oxford Radcliffe Hospitals NHS Trust Professor John Potter Professor in Geriatrics and Stroke Medicine.Appendix A: The Guideline Development Group Mr Alan Bowmaster Patient and carer representative. Hull Mrs Katherine Cullen Health Economist. NCC-CC NICE clinical guideline 68 – Stroke 32 . Addenbrooke's Hospital. Norwich Mrs Alison Richards Information Scientist. and Research Fellow. Newcastle upon Tyne Hospitals NHS Foundation Trust Mr Steve Hatton Emergency Care Practitioner. University of Birmingham Dr Andrew Molyneux Consultant Neuroradiologist. Cambridge University Hospitals NHS Foundation Trust Professor Gary Ford Professor of Pharmacology of Old Age. London Dr Richard McManus Clinical Senior Lecturer in Primary Care and General Practitioner. Queen Mary University of London Mrs Diana Day Stroke Specialist Research Nurse. National Collaborating Centre for Chronic Conditions (NCC-CC). Yorkshire Ambulance Service NHS Trust Mr Joseph Korner Patient and carer representative.
and Senior Lecturer/Honorary Consultant Stroke Medicine. Teignbridge PCT Dr Neil Baldwin Consultant in Stroke Medicine. Addenbrooke’s NHS Trust Mr Peter Lamont Consultant Vascular Surgeon. Guys and St Thomas’ Hospital NHS Trust Dr Sharon Swain Health Services Research Fellow in Guideline Development. NCC-CC Dr Pippa Tyrrell Guideline Development Group Clinical Advisor. Salford Royal NHS Foundation Trust Mr David Wonderling Senior Health Economist. NCC-CC Miss Claire Turner Guideline Development Senior Project Manager. United Bristol Healthcare Trust Mr Peter Kirkpatrick Consultant Neurosurgeon. Newcastle PCT NICE clinical guideline 68 – Stroke 33 . NCC-CC The following experts were invited to attend specific meetings and to advise the Guideline Development Group: Ms Rhoda Allison Consultant Therapist in Stroke. United Bristol Healthcare Trust Ms Mariane Morse Principal Speech and Language Therapist.Dr Anthony Rudd Guideline Development Group Chairman. and Consultant Stroke Physician. North Bristol Healthcare Trust (attended one meeting as a deputy for Dr John Potter) Mrs Julie Barker Senior Dietitian.
Oxford Radcliffe Hospitals NHS Trust Mr Sam Willis Paramedic Lecturer Practitioner. London Ambulance Service and Greenwich University (attended one meeting as a deputy for Mr Steve Hatton) NICE clinical guideline 68 – Stroke 34 .Professor Peter Rothwell Consultant Neurologist.
The panel includes members from the following perspectives: primary care.Appendix B: The Guideline Review Panel The Guideline Review Panel is an independent panel that oversees the development of the guideline and takes responsibility for monitoring adherence to NICE guideline development processes. North Tees PCT Ailsa Donnelly Lay member NICE clinical guideline 68 – Stroke 35 . lay. the panel ensures that stakeholder comments have been adequately considered and responded to. Cumbria Dr Mark Hill Head of Medical Affairs. Novartis Pharmaceuticals UK Dr John Harley Clinical Governance and Prescribing Lead. secondary care. Dr Robert Walker (Chair) General Practitioner. public health and industry. In particular.
NICE clinical guideline 68 – Stroke 36 .Appendix C: The algorithms These algorithms are provided as separate files: a TIA pathway (algorithm 1) and a stroke pathway (algorithm 2).
NASCET includes a measurement taken along a point of the internal carotid artery in a healthy area well beyond an area of the bulb that was caused by stenosis. arm weakness. FAST MUST Northern American Symptomatic Carotid Endarterectomy Trial (NASCET) European Carotid Surgery Trial (ECST) ROSIER NICE clinical guideline 68 – Stroke 37 . leg weakness. The minimum diameter of the arteries caused by stenosis (which is the maximum point of blood constriction) is compared with another diameter that represents the normal diameter of the carotid arteries when the patient is healthy. 1 point) B – blood pressure at presentation (≥ 140/90 mmHg. 1 point) D – Duration of symptoms (≥ 60 minutes. 1 point) The calculation of ABCD2 also includes the presence of diabetes (1 point). Used to screen for the diagnosis of stroke or TIA. Factors assessed include: demographic details. blood pressure and blood glucose concentration. speech disturbance without weakness. 10– 59 minutes. items on loss of consciousness and seizure activity. 1 point) C – clinical features (unilateral weakness. unintentional weight loss in the past 3–6 months. It incorporates current weight status (body mass index or an alternative measure). and the effect of acute disease on nutritional intake. 2 points. Total scores range from 0 (low risk) to 7 (high risk). and physical assessment including facial weakness. 2 points. based on a visual impression of where the normal artery wall was before development of the stenosis. speech disturbance and visual field defects. Face Arm Speech Test. Scale used to establish the diagnosis of stroke or TIA. Used to identify adults who are malnourished or at risk of malnutrition. The NASCET and ECST methods both indicate the degree of stenosis as a percentage reduction in vessel diameter. It is calculated based on: A – age (≥ 60 years. Recognition of Stroke in the Emergency Room. Facial weakness – can the person smile? Has their mouth or eye drooped? Arm weakness – can the person raise both arms? Speech problems – can the person speak clearly and understand what you say? Test all three symptoms. The ECST formula uses the estimated normal lumen diameter at the site of the lesion. Malnutrition Universal Screening Tool.Appendix D: Glossary of tools and criteria ABCD and ABCD2 Prognostic score to identify people at high risk of stroke after a TIA.
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